Nasal Decolonization Research Articles

Molecular Characterization of Nasal Methicillin-Resistant Staphylococcus aureus Isolates Showing Increasing Prevalence of Mupirocin Resistance and Associated Multidrug Resistance following Attempted Decolonization.

Sequential methicillin-resistant Staphylococcus aureus (MRSA) isolates from patients following attempted mupirocin nasal decolonization showed an increase in mupirocin resistance (MR) from 6.6% to 20%. MR isolates from patients who failed decolonization yielded indistinguishable spa types and carried multiple antimicrobial and antiseptic resistance genes, which may guide infection control and prevention.

Intracellular activity of antimicrobial compounds used for Staphylococcus aureus nasal decolonization.

Staphylococcus aureus is able to invade mammalian cells during infection and was recently observed inside nasal mucosa of healthy carriers. To determine the intracellular activity of antimicrobial compounds used for decolonization procedures using a cell model mimicking S. aureus nasal epithelium invasion. HaCaT cells and human nasal epithelial cells (HNECs) recovered from nasal swabs of S. aureus carriers were visualized by confocal laser scanning microscopy to detect intracellular S. aureus cells. An HaCaT cell model, mimicking S. aureus internalization observed ex vivo in HNECs, was used to assess the intracellular activity against S. aureus of 21 antimicrobial compounds used for nasal decolonization, including mupirocin and chlorhexidine. HaCaT cells and HNECs were found to internalize S. aureus with the same focal pattern. Most antimicrobial compounds tested on HaCaT cells were shown to have weak activity against intracellular S. aureus. Some systemic antimicrobials, including fusidic acid, clindamycin, linezolid, minocycline, ciprofloxacin, moxifloxacin, rifampicin and levofloxacin, reduced S. aureus intracellular loads by 0.43-1.66 log cfu/106 cells compared with the control (P < 0.001). By contrast, mupirocin and chlorhexidine reduced the S. aureus intracellular load by 0.19 and 0.23 log cfu/106 cells, respectively. These data indicate that most of the antimicrobial compounds used for nasal decolonization, including mupirocin and chlorhexidine, exhibit weak activity against intracellular S. aureus using the HaCaT cell model. This work emphasizes the need to better understand the role of the S. aureus intracellular reservoir during nasal colonization in order to improve decolonization procedures.

Chlorhexidine Versus Routine Bathing to Prevent Multi Drug-Resistant Organisms and All-Cause Bloodstream Infection in General Medical and Surgical Units: The ABATE Infection Cluster Randomized Trial

Background: Universal skin and nasal decolonization reduces multidrug-resistant pathogens and bloodstream infections in intensive care units. The effect of universal decolonization on pathogens and infections in non-critical care units is unknown. Methods: A two-arm cluster-randomized trial was conducted in 53 hospitals in the Hospital Corporation of America Healthcare system. Hospitals were randomized and their participating non-critical care units assigned to either routine care or daily chlorhexidine bathing for all patients plus mupirocin for known methicillin-resistant Staphylococcus aureus (MRSA) carriers. The trial involved a 12-month baseline (Mar 2013-Feb 2014) and 21-month intervention (Jun 2014-Feb 2016). Primary outcome was MRSA or vancomycin-resistant enterococcus (VRE) clinical cultures attributed to participating units, and secondary outcome was all-pathogen bloodstream infection. Proportional hazards models assessed differences in outcome reductions across arms, accounting for clustering by hospital. Post-hoc subgroup analyses were performed. Findings: There were 189,081 patients in the baseline period and 339,902 patients in the intervention period across 194 non-critical care units in 53 hospitals. Hazard ratios for MRSA/VRE clinical isolates during intervention vs. baseline periods were 0·87 (CI:0·79, 0·95) for routine care, and 0·79 (CI:0·73, 0·87) for decolonization (p=0·17), and 0·96 (CI:0·85, 1·08) and 0·90 (0·81, 1·01) for all-pathogen bloodstream infection, respectively (p=0·44). Among patients with central venous catheters, midline catheters, or lumbar drains, the hazard ratio for MRSA/VRE clinical cultures was 1·17 (CI:1·00, 1·37) for routine care and 0·80 (CI:0·69, 0·92) for decolonization, (p=0·0004), and the hazard ratio for all-pathogen bloodstream infections was 1·13 (CI:0·96, 1·33) for routine care and 0·82 (CI:0·71, 0·94) for decolonization, p=0·004. Interpretation: Decolonization with universal chlorhexidine bathing and targeted mupirocin for MRSA carriers did not reduce multidrug-resistant organisms or all-pathogen bloodstream infection in all non-critical care patients, but patients with invasive devices experienced 37% reduction in MRSA/VRE and 31% reduction in bloodstream infections. Clinical Trial Registration Number: clinicaltrials.gov Identifier: NCT0206386 Funding Statement: This project was funded by the National Institutes of Health Common Fund and administered by the National Institute of Allergy and Infectious Diseases (UH2/UH3 AT007769‐01 (Huang)). Declaration of Interest: Sage Products and Molnlycke contributed antiseptic chlorhexidine product to this trial. Investigators are also conducting other studies in which contributed antiseptic product is provided to participating hospitals and nursing homes from Stryker (Sage Products) (KK, LH, MHC, MKH, RAW, SSH), 3M (LH, SSH), Clorox (CS, ES, JH, JM, JP, KH, KK, LH, LS, MHC, MKH, RAW, RP, SSH, TRA), Xttrium (LH, SSH), and Medline (CS, ES, JH, JM, JP, KH, KK, LH, LS, MHC, MKH, RAW, RP, SSH, TRA). Investigator-initiated grant funds were received from Clorox (MKH, MHC, LS, KH, RP). Companies contributing product or providing grant funds have no role in the design, conduct, analysis, or publication of the ABATE Infection Trial or other studies conducted by these investigators. All other authors have no disclosures. Ethics Approval Statement: Central IRB approval was obtained from Harvard Pilgrim Health Care with a waiver of informed consent. All participating hospitals formally ceded IRB oversight to the HPHC IRB, except for the designated medical center IRB (Chippenham & Johnston Willis Hospitals) that provided prisoner oversight for the trial.

High prevalence of mupirocin resistance in methicillin resistant staphylococci and its clinical significance

Background: With the increasing pressure to prevent MRSA infections, it is possible that there will be increased use of Mupirocin for nasal decolonization of MRSA. Mupirocin is bacteriostatic at low concentration near the MIC for staphylococcus aureus but it is bactericidal at concentrations achieved by topical administration (20,000ug/ml) with the 2% formulation. Earlier reported High level Mupirocin resistance strain is associated with decolonization failure. The present study was carried out to determine the rates of high level and low level Mupirocin resistance (MuH and MuL) in methicillin resistant Staphylococcus aureus and methicillin resistant coagulase negative staphylococci. Materials and methods: A prospective study was carried out on 104 non-duplicate Staphylococcal isolates from various clinical specimens were tested for Mupirocin resistance using 5µg and 200µg discs. Detection of Mupirocin resistance was done by the disk diffusion method using 5 μg and 200 μg Mupirocin disks to determine low- and high-level resistance, respectively. Results: Mupirocin resistance was 7.8%, and 4.6% in MRSA and 40% and 20% in MR-CONS for 5 µg and 200 µg disc respectively. Conclusion: Institutions that are considering the implementation of widespread Mupirocin use should consider these resistance issues and develop strategies to monitor the impact of Mupirocin use. Perioperative prophylaxis with nasal mupirocin therapy (PPNMT) can reduce the incidence of MRSA SSls after orthopaedic surgery, probably by reducing nasal MRSA carriage in the endemic setting, without selecting for mupirocin resistance.

Thirteen-year experience with universal Staphylococcus aureus nasal decolonization prior to cardiac surgery: a quasi-experimental study

Sternal wound infection (SWI) after cardiac surgery is a severe complication. Among preventive measures, pre-operative decolonization of nasal carriage of Staphylococcus aureus has recently been shown to be beneficial. This quasi-experimental study assessed the effect of decolonization on the incidence of S.aureus-associated SWI based on 19 years of prospective surveillance. Segmented negative binomial regression was used to analyse the change over time in the incidence of S.aureus mediastinitis requiring re-operation after cardiac surgery in a French university hospital between 1996 and 2014. Universal nasal decolonization with mupirocin was introduced in December 2001. The association between pre-operative nasal carriage and SWI due to S.aureus was analysed between 2006 and 2012. Among 17,261 patients who underwent a cardiac surgical procedure, 565 developed SWI (3.3%), which was caused by S.aureus in 181 cases (1%). The incidence of mediastinitis caused by S.aureus decreased significantly over the study period (1.43% in 1996-2001 vs 0.61% and 0.64% in 2002-2005 and 2006-2014, respectively; P<0.001). In segmented analysis, there was a significant break in 2002, corresponding to the introduction of decolonization. Despite this intervention, pre-operative nasal carriage remained a significant risk factor for S.aureus mediastinitis (adjusted odds ratio 2.2; 95% confidence interval 1.2-4.2), as were obesity, critical pre-operative status, coronary artery bypass grafting (CABG), and combined surgery with valve replacement and CABG. Universal nasal decolonization before cardiac surgery was effective in decreasing the incidence of mediastinitis caused by S.aureus. Nasal carriage of S.aureus remained a risk factor for S.aureus-associated SWI.

Cessation from smoking improves innate host defense and clearance of experimentally inoculated nasal S. aureus

Abstract Staphylococcus aureus (SA) nasal carriage is transient in most humans and usually benign, but dissemination of SA to extranasal sites causes the majority of clinical infections, and SA is a major cause of serious infections in the U.S. A better understanding of innate nasal decolonization mechanisms is urgently needed, as are relevant models for studying SA clearance. Here, we screened a population of healthy smokers for nasal SA carriage, and compared participants’ abilities to clear experimentally applied nasal SA before and after completion of a smoking cessation program. We determined that cigarette smoking increases mean nasal SA load (2.6×104 CFU/swab) compared to healthy non-smokers (1.7×103 CFU/swab) and might increase the rate of SA nasal carriage in otherwise healthy adults: 22 of 99 smokers carried SA at the screening visit, while only 4 of 30 non-smokers screened positive during the same time period. Only 6 of 19 experimental inoculation studies in active smokers resulted in SA clearance within the month of follow-up, while in the cessation group, 6 of 9 subjects cleared nasal SA and carriage duration averaged 21±4 days. Smoking cessation associated with enhanced expression of SA-associated IL-1β and G-CSF in nasal fluids. Participants who failed to clear SA exhibited higher nasal SA load and elevated nasal interleukin-1 receptor antagonist (IL-1RA) expression at the pre-experiment study visits. We conclude that smokers exhibit higher SA load than non-smokers, and that innate immune pathways including G-CSF expression and signaling through the IL-1 axis are important mediators of nasal SA clearance.

Implementation of an infection prevention bundle and increased physician awareness improves surgical outcomes and reduces costs associated with spine surgery.

OBJECTIVE Previous studies have demonstrated the efficacy of infection prevention protocols in reducing infection rates. This study investigated the effects of the development and implementation of an infection prevention protocol that was augmented by increased physician awareness of spinal fusion surgical site infection (SSI) rates and resultant cost savings. METHODS A cohort clinical investigation over a 10-year period was performed at a single tertiary spine care academic institution. Preoperative infection control measures (chlorohexidine gluconate bathing, Staphylococcus aureus nasal screening and decolonization) followed by postoperative infection control measures (surgical dressing care) were implemented. After the implementation of these infection control measures, an awareness intervention was instituted in which all attending and resident neurosurgeons were informed of their individual, independently adjudicated spinal fusion surgery infection rates and rankings among their peers. During the course of these interventions, the overall infection rate was tracked as well as the rates for those neurosurgeons who complied with the preoperative and postoperative infection control measures (protocol group) and those who did not (control group). RESULTS With the implementation of postoperative surgical dressing infection control measures and physician awareness, the postoperative spine surgery infection rate decreased by 45% from 3.8% to 2.1% (risk ratio 0.55; 95% CI 0.32-0.93; p = 0.03) for those in the protocol cohort, resulting in an estimated annual cost savings of $291,000. This reduction in infection rate was not observed for neurosurgeons in the control group, although the overall infection rate among all neurosurgeons decreased by 54% from 3.3% to 1.5% (risk ratio 0.46; 95% CI 0.28-0.73; p = 0.0013). CONCLUSIONS A novel paradigm for spine surgery infection control combined with physician awareness methods resulted in significantly decreased SSI rates and an associated cost reduction. Thus, information sharing and physician engagement as a supplement to formal infection control measures result in improvements in surgical outcomes and costs.

Cessation from Smoking Improves Innate Host Defense and Clearance of Experimentally Inoculated Nasal Staphylococcus aureus.

Staphylococcus aureus nasal carriage is transient in most humans and usually benign, but dissemination of S. aureus to extranasal sites causes the majority of clinical infections, and S. aureus is a major cause of serious infections in the United States. A better understanding of innate nasal decolonization mechanisms is urgently needed, as are relevant models for studying S. aureus clearance. Here, we screened a population of healthy smokers for nasal S. aureus carriage and compared the participants' abilities to clear experimentally applied nasal S. aureus before and after completion of a smoking cessation program. We determined that cigarette smoking increases the mean nasal S. aureus load (2.6 × 104 CFU/swab) compared to the load observed in healthy nonsmokers (1.7 × 103 CFU/swab) and might increase the rate of S. aureus nasal carriage in otherwise-healthy adults: 22 of 99 smokers carried S. aureus at the screening visit, while only 4 of 30 nonsmokers screened positive during the same time period. Only 6 of 19 experimental inoculation studies in active smokers resulted in S. aureus clearance within the month of follow-up, while in the cessation group, 6 of 9 subjects cleared nasal S. aureus and carriage duration averaged 21 ± 4 days. Smoking cessation associated with enhanced expression of S. aureus-associated interleukin-1β (IL-1β) and granulocyte colony-stimulating factor (G-CSF) in nasal fluids. Participants who failed to clear S. aureus exhibited a higher nasal S. aureus load and elevated nasal interleukin-1 receptor antagonist (IL-1RA) expression at the preexperiment study visits. We conclude that smokers exhibit higher S. aureus loads than nonsmokers and that innate immune pathways, including G-CSF expression and signaling through the IL-1 axis, are important mediators of nasal S. aureus clearance.

Periprotetske infekcije - činimo li sve da ih prepoznamo i sprečimo? (Periprotetske infekcije)

Total hip and total knee arthroplasty improve quality of life and reduce pain in patients with severe joint diseases. Despite the widely reported success of the procedures, periprosthetic joint infection (PPI), as complication, affects approximately 1% of patients after joint arthroplasty leading to poor surgical outcomes, osteomyelitis, sepsis, multiorgan dysfunction and even death. The treatment includes timely performed open debridement and exchange of all mobile parts of the prosthesis and antibiotics that can prevent formatting bacterial biofilm over the implants surface or penetrate into them. Management of PPI is expensive and presents economic burden on the health care system. Therefore, prevention and identification of potential risk factors is of great importance. Patient related risk factors for PPI include gender, alcohol abuse, higher body mass index, cardiovascular, pulmonary, renal, gastrointestinal, rheumatological and oncological disease, diabetes, immunosuppression, preoperative infection and depression. Moreover, perioperative complications, other conditions like hypothermia, longer hospital stay, blood transfusion and reoperation also increase risk for PPI. PPI prevention measures need to be implemented in the preoperative, perioperative and postoperative period. Preventive measures include nasal decolonization, preoperative skin cleansing, reduced doses of intraarticular injections and immunosuppressive therapy, glycemic control, antibiotic prophylaxis, laminar air flow, orthopedic space suits, operating theatre traffic, surgical site preparation, normothermia, the use of erythropoietin and tranexamic acid.

Prophylaxis with nasal decolonization in patients submitted to total knee and hip arthroplasty: systematic review and meta-analysis

Despite the evolution of the total knee and hip arthroplasty surgery, high postoperative complication rates in the short and long term still persist. Infection is one of the most challenging complications; due to its gravity and treatment difficulties, prophylaxis protocols have been created to decrease its incidence. The objective of this study was to evaluate the impact of the prophylaxis protocol for methicillin-resistant Staphylococcus aureus decolonization of the nares in patients previously identified by swab cultures, who were to be submitted to a total joint arthroplasty. A systematic review with meta-analysis was conducted, following the PRISMA-2015 protocol, using the descriptors: “arthroplasty” and “nasal decolonization,” or “joint arthroplasty” and “decolonization,” or “joint arthroplasty” and “nasal decolonization,” for final selection of four observational studies from 79 references identified. This study included a total sample of 10,179 patients, divided in two groups: the control group (4788 patients) and intervention group (5391 patients). It was observed that the intervention group, in which prophylaxis with nasal decolonization was used, 59 (1.09%) of the patients developed a surgical site infection, while in the control group there were 86 cases of surgical site infection (1.79%). This trend repeated itself in all articles, showing no publication biases, forming a homogeneous sample. The use of a prophylaxis protocol for decolonization of methicillin-resistant Staphylococcus aureus, reduced surgical site infection cases by approximately 39%.

Daily Chlorhexidine Bathing in General Hospital Units – Results of the ABATE Infection Trial (Active BAThing to Eliminate Infection)

Daily Chlorhexidine Bathing in General Hospital Units – Results of the ABATE Infection Trial (Active BAThing to Eliminate Infection)

NP108, an Antimicrobial Polymer with Activity against Methicillin- and Mupirocin-Resistant Staphylococcus aureus.

ABSTRACTStaphylococcus aureus is a clinically significant human pathogen that causes infectious diseases ranging from skin and soft tissue infections (SSTI) and health care-associated infections (HAI) to potentially fatal bacteremia and endocarditis. Nasal carriage of S. aureus, especially for persistent carriage, is associated with an increased risk of subsequent infection, particularly nosocomial and surgical site infections (SSI), usually via autoinfection. NP108 is a cationic antimicrobial polymer composed of generally recognized as safe (GRAS) amino acid building blocks. NP108 is broad spectrum and rapidly bactericidal (3-log kill in ≤3 h), killing bacteria by membrane disruption and cell lysis. NP108, contrary to many antibiotics, shows equally effective antimicrobial activity against a variety of S. aureus (MIC100 = 8 to 500 mg/liter) and S. epidermidis (MIC100 = 4 to 8 mg/liter) isolates, whether exponentially growing or in stationary phase. NP108 is antimicrobially active under nutrient-limiting conditions similar to those found in the anterior nares (MIC100 = 8 mg/liter) and kills antibiotic-resilient small colony variants (MIC100 = 32 mg/liter) and S. aureus biofilms (prevention, MIC100 = 1 to 4 mg/liter; eradication, MIC100 ≥ 31.25 mg/liter). NP108 is active against isolates of S. aureus resistant to the current standard-of-care decolonization agent, mupirocin, with no significant increase in the MIC100. NP108 is water soluble and has been formulated into compatible aqueous gel vehicles for human use in which antimicrobial efficacy is retained (2.0% [wt/vol]). NP108 is a potential nonantibiotic antimicrobial alternative to antibiotics for the nasal decolonization of S. aureus, with clear advantages in its mechanism of action over the existing gold standard, mupirocin.

Povidone-Iodine–Based Solutions for Decolonization of Nasal Staphylococcus aureus: A Randomized, Prospective, Placebo-Controlled Study

BackgroundNasal Staphylococcus aureus decolonization reduces the risk of surgical site infections after orthopedic procedures. Povidone-iodine (PI)-based solutions have shown promising results in bacteria decolonization. The unique physiology of the nose may pose challenges for the bioactivity profiles of PI solutions. This study compared the antibacterial efficacy of an off-the-shelf PI product with a specifically manufactured PI-based skin and nasal antiseptic (SNA). MethodsThis randomized, placebo-controlled study was conducted at a single institution between April 2014 and July 2015. Four hundred and twenty-nine patients undergoing primary or revision total joint arthroplasty, femoroacetabular osteoplasty, pelvic osteotomy, or total shoulder arthroplasty were included. 10% off-the-shelf PI, 5% PI-based SNA, or saline (placebo) were used for nasal decolonization. Baseline cultures were taken immediately preoperatively, followed by treatment of both nares twice for 2 minutes with 4 applicators. Reculturing of the right nostril occurred at 4 hours and the left at 24 hours. ResultsNinety-five of the 429 patients (22.1%) had a positive culture result for S. aureus; 13 (3.03%) were methicillin-resistant S. aureus. Of these 95, 29 were treated with off-the-shelf PI, 34 with SNA, and 32 with saline swabs. At 4 hours post-treatment, S. aureus culture was positive in 52% off-the-shelf PI patients, 21% SNA patients, and 59% saline patients. After 24 hours posttreatment, S. aureus culture was positive in 72% off-the-shelf PI patients, 59% SNA patients, and 69% saline group. SNA was significantly more effective at decolonizing S. aureus over the 4-hour time interval (P = .003); no significant difference was observed over the 24-hour time interval between the 3 groups. ConclusionA single application of PI-based SNA before surgery may be effective in eliminating nasal S. aureus in over two-thirds of patients. Off-the-shelf PI swabs were not as effective at 4 hours as the specifically manufactured product for S. aureus decolonization

Future Research Opportunities in Peri-Prosthetic Joint Infection Prevention.

Peri-prosthetic joint infection (PJI) is a serious complication of prosthetic joint arthroplasty. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSI). Recently, the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) published the Guideline for Prevention of Surgical Site Infection. This targeted update applies evidence-based methodology in drafting recommendations for potential strategies to reduce the risk of SSI both across surgical procedures and specifically in prosthetic joint arthroplasty. A panel of PJI content experts identified nine PJI prevention research opportunities based on both evidence gaps identified through the guideline development process (transfusion, immunosuppressive therapy, anticoagulation, orthopedic space suit, and biofilm) and expert opinion (anesthesia, operative room environment, glycemic control, and Staphylococcus aureus nasal screening and decolonization. This article offers a road map for PJI prevention research.

Vancomycin heteroresistant community associated methicillin-resistant Staphylococcus aureus ST72-SCCmecIVa strain colonizing the nostrils of a five-year-old Spanish girl

Background and objectivesDuring a community methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization study, an MRSA strain with vancomycin hetero-resistance (h-VISA) was isolated from a five year-old girl with tetralogy of Fallot without previous exposure to vancomycin. An extended nasal colonization study was performed on all her close relatives. ResultsOnly the patient and her sister were colonized by an h-VISA MRSA strain (clone USA 700, ST72, t148, agr 1 and SCCmec IVa). Mupirocin decolonisation was effective in the elder sister. A new nasal decolonisation in the younger girl using fusidic acid was also successful. However, after decolonisation both sisters were colonized by a methicillin-susceptible S. aureus (ST30, t012 and agr 3) previously isolated from their mother's nostrils. ConclusionAs S. aureus have a great capacity to spread among people in close contact, knowledge of a patients’ colonization status, tracing contacts, and a correct management are critical issues for the successful containment of multiresistant staphylococci.

Profilaxia com descolonização nasal em pacientes submetidos a artroplastia total de joelho e quadril: revisão sistemática com metanálise

Despite the evolution of the total knee and hip arthroplasty surgery, high postoperative complication rates in the short and long term still persist. Infection is one of the most challenging complications; due to its gravity and treatment difficulties, prophylaxis protocols have been created to decrease its incidence. The objective of this study was to evaluate the impact of the prophylaxis protocol for methicillin‐resistant Staphylococcus aureus (MRSA) decolonization of the nares in patients previously identified by swab cultures, who were to be submitted to a total joint arthroplasty. A systematic review with meta‐analysis was conducted, following the PRISMA‐2015 protocol, using the descriptors: “arthroplasty” and “nasal decolonization,” or “joint arthroplasty” and “decolonization,” or “joint arthroplasty” and “nasal decolonization,” for final selection of four observational studies from 79 references identified. This study included a total sample of 10,179 patients, divided in two groups: the control group (4,788 patients) and intervention group (5,391 patients). It was observed that the intervention group, in which prophylaxis with nasal decolonization was used, 59 (1.09%) of the patients developed a surgical site infection (SSI), while in the control group there were 86 cases of SSI (1.79%). This trend repeated itself in all articles, showing no publication biases, forming a homogeneous sample. The use of a prophylaxis protocol for decolonization of MRSA, reduced SSI cases by approximately 39%.

Systematic review of a patient care bundle in reducing staphylococcal infections in cardiac and orthopaedic surgery

Surgical site infections (SSIs) are serious adverse events hindering surgical patients' recovery. In Australia and New Zealand, SSIs are a huge burden to patients and healthcare systems. A bundled approach, including pre-theatre nasal and/or skin decolonization has been used to reduce the risk of staphylococcal infection. The aim of this review is to assess the effectiveness of the bundle in preventing SSIs for cardiac and orthopaedic surgeries. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Published literature was searched in PubMed, Embase and Cochrane Library of Systematic reviews. Identified articles were selected and extracted based on a priori defined Population-Intervention-Comparator-Outcome and eligibility criteria. Data of randomized controlled trials (RCTs) and comparative observational studies were synthesized by meta-analyses. Quality appraisal tools were used to assess the evidence quality. The review included six RCTs and 19 observational studies. The bundled treatment regimens varied substantially across all studies. RCTs showed a trend of Staphylococcus aureus SSIs reduction due to the bundle (relative risk = 0.59, 95% confidence interval (CI) = 0.33, 1.06) with moderate heterogeneity. Observational studies showed statistically significant reduction in all-cause and S. aureus SSIs, with 51% (95% CI = 0.41, 0.59) and 47% (95% CI = 0.35, 0.65), respectively. No publication biases were detected. SSIs in major cardiac and orthopaedic surgeries can be effectively reduced by approximately 50% with a pre-theatre patient care bundle approach.

Perioperative participation of orthopedic patients and surgical staff in a nasal decolonization intervention to reduce Staphylococcus spp surgical site infections

With the goal of reducing rates of surgical site infections in our spine patients, we initiated a trial to investigate the impact of adding perisurgical nasal decolonization involving patients and surgical and nursing staff. We combined immediate presurgical application of a nonantibiotic alcohol-based nasal antiseptic with existing chlorhexidine bath or wipes in a comprehensive pre- and postoperative decolonization protocol. Mean infection rates were significantly decreased by 81% from 1.76 to 0.33 per 100 surgeries during the 15-month trial, when compared with the prior 9-month baseline.

Eradication of &amp;lt;i&amp;gt;Staphylococcus aureus&amp;lt;/i&amp;gt; and MRSA in the Nares: A Historical Perspective of the Ecological Niche, with Suggestions for Future Therapy Considerations

Nasal colonization with pathogenic bacteria continues to present challenges for patients undergoing surgical procedures, and for the physicians that treat them. Even as molecular medicine produces ever faster and improved data sets for clinicians, it would benefit all medical personnel attempting to decolonize the nose to better understand the historical nasal decolonization data with specific reference to the ecological niche for these bacteria, as it has been recorded for more than a century. Much of the historical data points to the largest ecological niche for nasal Staphylococcus aureus as the vibrissae of the vestibulum nasi. A careful study shows that any topical antimicrobial preparation needs to successfully penetrate the deepest recesses of these specialized nasal hair follicles, if decolonization is to be adequately accomplished. This review highlights the most relevant data of the last 140 years concerning the staphylococcal ecological niche of the vibrissae. Also to be discussed will be a historical review of topical Mupirocin. Almost thirty years after its FDA approval, Mupirocin is still the most widely used topical antibiotic for decolonization therapy around the world. Correspondingly, new experimental in vitro data will be presented showing the differing efficacy of Mupirocin against multiple strains of HA-MRSA and CA- MRSA, based solely on the commercial topical formulation (non Mupirocin ingredients) that acts synergistically with the Mupirocin. Finally, the review will discuss why an understanding of these historical data is a vital component to integrate into any new or augmented nasal decolonization therapy.

Mimics of Host Defense Proteins; Strategies for Translation to Therapeutic Applications.

New infection treatments are urgently needed to combat the rising threat of multi-drug resistant bacteria. Despite early clinical set-backs attention has re-focused on host defense proteins (HDPs), as potential sources for new and effective antimicrobial treatments. HDPs appear to act at multiple targets and their repertoire includes disruptive membrane and intracellular activities against numerous types of pathogens as well as immune modulatory functions in the host. Importantly, these novel activities are associated with a low potential for emergence of resistance and little crossresistance with other antimicrobial agents. Based on these properties, HDPs appear to be ideal candidates for new antibiotics; however, their development has been plagued by the many therapeutic limitations associated with natural peptidic agents. This review focuses on HDP mimetic approaches aimed to improve metabolic stability, pharmacokinetics, safety and manufacturing processes. Early efforts with β-peptide or peptoid analogs focused on recreating stable facially amphiphilic structures but demonstrated that antimicrobial activity was modulated by more, complex structural properties. Several approaches have used lipidation to increase the hydrophobicity and membrane activity. One lead compound, LTX-109, has entered clinical study as a topical agent to treat impetigo and nasal decolonization. In a more significant departure from the amino acid like peptidomimetics, considerable effort has been directed at developing amphiphilic compounds that recapitulate the structural and biological properties of HDPs on small abiotic scaffolds. The lead compound from this approach, brilacidin, has completed two phase 2 studies as an intravenous agent for skin infections.